Second-Line Salvage Treatment of AIDS-Associated Pneumocystis jirovecii Pneumonia: A Case Series and Systematic Review.

BACKGROUND:: Limited clinical data exist to guide the choice of second-line salvage treatment for AIDS-associated Pneumocystis jirovecii pneumonia (PCP). METHODS:: We did a systematic search of MEDLINE for all randomized and observational studies of PCP treatment published up to August 2007 and included individual treatment data of AIDS-associated PCP from a tricenter study. We calculated pooled estimates of reported outcome of second-line treatment using averaged odds ratios (ORs). RESULTS:: Twenty-nine studies with sufficient detail of second-line treatment and outcome, including data from 82 individual cases from the tricenter study, yielded a total of 468 PCP second-line treatment episodes. Response rates to second-line treatment were comparable for trimethoprim-sulfamethoxazole (TMP-SMX; 68%) and clindamycin-primaquine (73%) (OR for response = 2.1 [95% confidence interval (CI): 1.1 to 3.2] and 2.7 [95% CI: 1.3 to 4.0]), respectively) but were considerably lower for intravenous pentamidine (44%; OR = 0.8 [95% CI: 0.6 to 1.0]). CONCLUSIONS:: Clindamycin-primaquine is an alternative to intravenous pentamidine as second-line treatment for PCP in patients who fail treatment with TMP-SMX. TMP-SMX should be used as a second-line treatment for those failing first-line treatments with regimens other than TMP-SMX.

Benfield T, Atzori C, Miller RF, Helweg-Larsen J.

From the *Department of Infectious Diseases, Hvidovre University Hospital, University of Copenhagen, Copenhagen, Denmark; †II Department of Infectious Diseases, Luigi Sacco Hospital, Milan, Italy; ‡Centre for Sexual Health and HIV Research, University College London, London, United Kingdom; and the §Department of Infectious Diseases, Copenhagen University Hospital, University of Copenhagen, Copenhagen, Denmark.